Congratulations — the dental plan paid the claim! Or did they? Confirmation that your claim has been processed comes in two forms: payment and/or an explanation of benefits. An EOB is sent to the patient and/or dental office as a receipt of services provided. Unfortunately, dental plans do not have standardized formats for these documents, which is why it’s necessary for an office to read the EOB completely.

Many dental benefit plans have adopted contracting based on the contract of the treating dentist, not just the billing (owner) dentist. When billing a benefit plan, the information documented on the claim in the billing dentist or billing entity, treating dentist and treatment location sections must all be accurate. If the treating dentist documented on the claim differs from the treating dentist noted in the patient’s chart, it’s considered to be fraudulent billing.

As the dental benefits analyst for CDA Practice Support, my job is to help dentists navigate the ever-changing dental benefits marketplace, and this entails clearing up misconceptions that could place a dentist at risk. In my conversations with dentists who are selling or buying a practice, I’ve found some misconceptions concerning billing dental benefit plans following the sale of a practice.

Every year, CDA encourages all dentists to prepare for dental code additions, revisions and deletions. The ADA has released the CDT 2019 with 15 additions, five revisions and four deletions that will go into effect Jan. 1. It is recommended that all dental offices have a current copy of the CDT to assist with proper claim billing. Typically, plans will start sending updates about policy changes for the new year during the fourth quarter.

Some events in life, such as the birth of a child or certain medical procedures, can be planned or controlled. But there are times when circumstances are outside of our control, such as with injury or unexpected death. In this article, we address how your absence in the practice could result in dental claim processing issues and how having a plan of action in place can reduce complications during these times.

Greg Alterton is approaching his 16-year anniversary with CDA. He worked in the CDA Public Policy Division for 13 of those 16 years, where he was involved in developing dental benefits legislation sponsored by CDA. He has assisted individual members directly with their dental benefit issues while in Public Policy and during the past three years with CDA Practice Support. He retires from CDA at the end of 2017.

CDA encourages all dentists to prepare for CDT 2018 dental code additions, revisions and deletions that go into effect Jan. 1, 2018. The new year will bring 18 new procedure codes, 16 revisions and three deletions. While dental plans are required to recognize current CDT codes, it is important to keep in mind that they are not required to pay for or provide benefits for the new or revised codes. Dentists should review each dental plan’s payment and processing guidelines to determine whether benefits will be payable.

Have you ever had one of those moments when you received a decision from a dental benefit plan and thought, “There ought to be a law?” Well, there isn’t a law, in many cases. All health plans must meet requirements as determined by the state agencies that regulate, license and certify them. However, the issues that matter most to providers as well as patients — what is included in the plan’s scope of benefits, for example — are not governed by state laws or regulations.

CDA Practice Support occasionally hears a complaint from dental offices that a plan granted a preauthorization for treatment and then denied payment when the claim was submitted. Digging a little deeper into these complaints, there may be some confusion between what constitutes a “preauthorization” and what is a “predetermination” or pre-estimate of benefits.

CDA reminds dentists that the Centers for Medicare and Medicaid Services last October moved the Medicare Part D enrollment deadline from Feb. 1, 2017, to Jan. 1, 2019. Dentists should either enroll as a Medicare Part D "ordering/referring provider" or opt out of the Medicare program entirely by the January 2019 deadline.

Collections is one of the most crucial and challenging aspects of practice management. Using a collections protocol is a basic first step in addressing unpaid balances, but if phone calls and letters go unanswered, a dentist is faced with the dilemma of whether to turn the account over to a collection agency. TDIC advises dentists to carefully consider the pros and cons of such an action.

Beginning in the New Year, and with the forthcoming issue of the CDA Update, the dental benefits column will host a semiregular series discussing basic dental benefit issues. The topics covered address questions that CDA Practice Support receives from dental offices and from local dental components. This first installment addresses proper billing for treatment provided by an associate and waiving of co-payments.

Recently, Practice Support has received questions about whether the dental plans that dentists are contracted with can dictate fees for treatment on procedures that the plans don’t cover. The answer can be found in CDA-sponsored legislation that became effective in 2011.

Over the past year, CDA has received phone calls from member dentists about dental claim payment issues with the Blue Shield of California Federal Employee Program. CDA reached out to Blue Shield of California to obtain information and seek a resolution that ensures more timely payment for dentists who treat federal employees.

As the dental marketplace continues to change, hiring associates and having a multidentist practice is increasingly more common. CDA Practice Support frequently receives inquiries from members regarding how to correctly bill for associate dentists providing treatment in their practice.

AB 72 furthers consumer protections while also making it easier for physicians to resolve reimbursement problems with insurers. Under this bill, out-of-network physicians providing treatment at an in-network hospital or clinic must receive a patient’s voluntary consent to be treated for out-of-network care at least one day before the treatment.

The dental plan industry reports that more than 70 percent of dental claims received by plans are sent electronically. In California, that number is closer to 75 percent. Practice management software, and the standardization of forms for electronic transactions, have made this possible.

There is an ongoing trend within health care toward integration and consolidation of health care delivery systems. This trend is reflected in provisions of the federal Affordable Care Act, such as the envisioned coordination of care provided under a single entity, the “Accountable Care Organization.”

As the dental marketplace continues to change, hiring associates and having a multi-dentist practice is increasingly more common. CDA Practice Support receives frequent inquiries from members regarding the correct way to bill for associate dentists providing treatment in their practice.

EMV (Europay/MasterCard/Visa) will eventually replace the magnetic stripe on credit cards that has been the standard in the United States since 1960, and dental practices should be ready for this transition. Acceptance of EMV will not technically be mandated for practices that accept credit or debit cards, but a shift in fraud liability began in October.

CDA Practice Support receives many questions from members about dental benefits. Two of the most common questions are about patient copayments and patient discounts for prepayments. Here are answers to both.

CDA receives numerous calls daily about various disputes dentists have with patients’ dental benefit carriers. While CDA will consider how these disputes might be informally resolved, ultimately, the dentist has the right to appeal the dispute back to the plan, and eventually with the plan’s regulator.

United Concordia changed how periapical X-rays would be paid this summer and CDA Practice Support, after receiving calls from members about the changes, reached out to the company on behalf of dentists to get additional information. Here are the aspects of the new policy that CDA has learned from its correspondence with the insurance company.

The Centers for Medicare and Medicaid Services (CMS) has set the implementation date of the International Classification of Diseases version 10 Clinical Modification (ICD-10 CM) for Oct. 1. While the implementation of ICD-10 CM affects a limited number of dentists in California, such as oral surgeons, anesthesiologists, pathologists, etc., it is important to note that all dentists should be aware that diagnostic coding could become a requirement in the future.

As part of a contractual commitment the dental benefit plans have with their consumers (employer groups and their employees), they are required to have a utilization review process. Recently, CDA has received an increase in calls about these types of reviews by the dental plans. Utilization review is a post-claims review process that can affect dentists who treat patients covered by a dental benefit company.

Medical/dental necessity will always be the rationale for most dental care, but medical/dental necessity may not be the basis of how plans pay. Dentists often wonder what the top reasons are for claims being denied. Here are some simple reasons why.

Navigating the dynamic world of dental benefits is key to managing a smart practice. The Dental Benefits Workshop provides participants the opportunity to earn 12 C.E. credits during a two-day, in-person seminar. They will learn how to analyze and evaluate existing dental plan performance in their offices while getting hands-on experience from industry experts on how to navigate the world of dental benefits.

Mireya Ortega, DDS, thought she had taken all of the necessary steps in the insurance approval and billing process for her patient. But despite doing everything according to the insurance policy standard she was sent a letter in the mail informing her she needed to return all of the money she had received for the treatment because the patient in fact did not have coverage. That is when she called CDA Practice Support.

The federal Centers for Medicare and Medicaid Services (CMS) has again changed the compliance date for dentists desiring to opt out of the Medicare program. The new date, June 1, 2016, comes some two weeks after CMS moved the date from June 1 of this year to Jan. 1 of next year.

The Centers for Medicare and Medicaid Services (CMS) has announced that the new compliance date for enrollment or opt out for dentists to the Medicare program is Jan. 1, 2016. The original deadline was June 1. Dentists are encouraged to consider June 1 as a soft compliance date to get their forms in so as not to have their status or patient benefits lapse while forms are being processed.

Attendees of CDA’s recent Dental Benefits Workshop at the CDA headquarters in Sacramento had the opportunity to earn C.E. credits while learning how to analyze and evaluate existing dental plan contract performance in their practices. The more than 70 people, including dentists and staff from 40 practices, who attended the April 16-17 event earned up to 12 hours of C.E. and improved their skills in analyzing and evaluating the dental benefit marketplace.

Increasingly, dental plans are deferring to medical benefit carriers on certain dental procedures that can be claimed as medical procedures with patients’ medical plans. More and more, these medical plans are paying for not only surgical dental procedures, but some preventive dental services as well. In submitting claims to medical plans, dentists need to be aware of and prepare for the adoption of new medical diagnostic codes that will be in use beginning Oct. 1.

With more than 700 dentists graduating from California dental schools recently, there is a wave of newly licensed professionals surfing the web and hitting the streets in search of job opportunities as associates in dental practices around the state. Simultaneously, more experienced CDA members may be expanding their practices by bringing in associate dentists as part of their long-term strategic plan. The issues surrounding dental benefit plan billing can become more confusing for the dentist(s) and office teams due to the new addition of a dentist to a practice.